The Medicare Incentive Program for e-prescribing

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1 Welcome To The Digital Learning Center Presented by Your Partner In Building High Performance Practices Today s Presentation The Medicare Incentive Program for e-prescribing Course Faculty R. Thomas (Tom) Loughrey, MBA, CCS-P Chairman, CEO & Co-Founder of Economedix Certified Coding Specialist BS Degree from Pennsylvania State University Earned an MBA in Health & Hospital Administration from the University of Florida Former Hospital Administrator Former Owner of a Medical Billing Company Consultant to Physician Practices & Medical Societies Member of Various Professional Organizations Dealing with Medical Practice Management Developed and Presented Thousands of Seminars & Workshops Dealing with Practice Management

2 What is the e-prescribing Program? The Medicare e-prescribing incentive is a new program authorized under the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) The program begins January 1, 2009 The e-prescribing Incentive Program is currently based on one e-prescribing Quality Measure that is currently included in the Physician Quality Reporting Initiative (PQRI) Beginning in 2009, the e-prescribing Quality Measure will be removed from the PQRI, and it will become the quality measure used in the e- Prescribing Incentive Program What is the e-prescribing Program? For 2009, e-prescribing incentive amounts will be 2% of the total estimated allowed charges for professional services covered by Medicare Part B and furnished by an eligible professional during the reporting period (one calendar year) What is the e-prescribing Program? If you are a successful e-prescriber Your Incentive payment is: % % % % % All claims must be submitted no later than tw o months follow ing the close of the year

3 Eligibility for Incentive To be eligible for the incentive in 2009, you must be an eligible professional whose estimated allowed Medicare Part B charges for the e-prescribing measure codes are at least 10% of your total Medicare Part B allowed charges Example: If estimated total allowed charges are $100,000 then at least $10,000 in allowed charges must come from specified HCPCS codes (see next page) Eligibility for Incentive o Billing codes used in conjunction with the e-prescribing Program G G G Who Is An Eligible Professional? In general, an eligible professional is one of the following: Physician Physical or occupational therapist Qualified speech-language pathologist Nurse practitioner Physician assistant Clinical nurse specialist Certified registered nurse anesthetist Certified nurse midwife Clinical social worker Clinical psychologist Registered dietitian Nutrition professional Qualified audiologist (as of 2009)

4 What Is A Successful e- Prescriber? For 2009, to be a successful e- Prescriber, you must report the e- prescribing quality measure through your Medicare Part B claims on at least 50% of applicable cases during the reporting year. MIPPA allows for future use of Part D data instead of claims-based reporting of e-prescribing quality measures. CMS is considering allowing this for future years. Choosing a e-prescribing System To participate in the E-prescribing Incentive Program, you must use a qualified e- Prescribing System. There are two types of systems: - A system for e-prescribing only (a standalone system), - or an electronic health record (EHR) system with e-prescribing functionality. Either of these systems may be used for the incentive program, as long as they are qualified. Choosing a e-prescribing System A qualified system must be able to do the following: 1. Generate a complete medication list that incorporates data from pharmacies and benefit managers (if available) 2. Select medications, transmit prescriptions electronically using the applicable standards, and warn the prescriber of possible undesirable or unsafe situations

5 Choosing a e-prescribing System A qualified system must be able to do the following: 3. Provide information on lower-cost, therapeuticallyappropriate alternatives (for 2009, tiered formulary information, if available, meets this requirement) 4. Provide information on formulary or tiered formulary medications, patient eligibility, and authorization requirements received electronically from the patient s drug plan. The prescription must be sent electronically. Choosing a e-prescribing System If the network converts the electronic prescription into a fax because the pharmacy can t get electronic faxes, this counts as e- Prescribing. If the e-prescribing system is only capable of sending a fax directly from the e-prescribing System to the pharmacy, the system isn t a qualified e-prescribing system. Detailed system requirements are in Measure #125 at Questions to Consider in Selecting a System Do you want a stand-alone system or one that is part of an EHR? Stand-alone systems are the cheapest and fastest to implement, but EHRs have additional features that are helpful in managing a medical practice over the long run.

6 Questions to Consider in Selecting a System Does the system use Medicare Part D standards? Will it be updated as needed? It s important to understand the system s features and how they work. Remember, to qualify for the e-prescribing incentive, you must use a system that has the features listed previously. To understand if the system is qualified and uses Medicare Part D standards, review A Clinician s Guide to Electronic Prescribing. This publication contains a buyer s guide to help you compare e-prescribing systems. To access it, visit Getting Help Paying for A System A Clinician s Guide to Electronic Prescribing at There are also parameters for technology donations so that under certain conditions, providers can accept donations without violating the Stark law or the Anti-Kickback Statute. For more information about the Stark law and Anti-Kickback Statute, visit either of the two websites below: Getting Help Paying for A System Many states have developed web-based e- Prescribing Systems that don t require providers to have additional software. While these systems are designed to operate with the State Medicaid program, some may also be able to handle Medicare prescriptions and claims. Providers can adopt these systems at little or no cost. Because state systems vary, you should check with your State Medical Assistance (Medicaid) office about their e-prescribing activities. Check with your local hospital to see if they are providing any financial assistance

7 How to Report the e- Prescribing Incentive Measure Step 1: Bill one of the denominator G G G How to Report the e- Prescribing Incentive Measure If you used a qualified e-prescribing system for all of the prescriptions Report G8443 If you had a qualified e-prescribing system, but didn t generate any prescriptions during this encounter Report G8445 If you had a qualified e-prescribing system, but prescribed narcotics or other controlled substances Report G8446 How to Report the e- Prescribing Incentive Measure If you had a qualified e-prescribing system, and state or Federal law required you to phone in or print the prescriptions Report G8446 If you had a qualified e-prescribing system, and the patient asked that you phone in or print the prescriptions Report G8446 If you had a qualified e-prescribing system, and the pharmacy system can t receive electronic transmission Report G8446

8 How to Report the e- Prescribing Incentive Measure To report a Measure Code (G8443, G8445, G8446) List code on claim with no charge If your system requires a charge use $0.01 (it will not be paid) The code does not need to link to a ICD-9 code If your system requires it, link to the primary diagnosis How to Report The e- Prescribing Incentive Measure The Drug Enforcement Agency (DEA) currently prohibits e-prescribing for controlled substances. The DEA has issued a proposed rule to allow e-prescribing for controlled substances under certain conditions. Even if the DEA allows e-prescribing for controlled substances, G-code G8446 allows you to report on the e-prescribing measure for controlled substances without using an e-prescribing system to do so What s Next? On April 1, 2009, additional and revised standards for e-prescribing under the Medicare Part D program will go into effect. These additional standards complement the existing foundation standards, which cover eligibility transactions and transmitting prescriptions and prescription-related information between prescribers and dispensers.

9 What s Next? Differential Payment for Not e-prescribing goes into effect 2012 Eligible professionals who are not successful e-prescribers by 2012 will be subject to a differential payment (penalty) beginning in The differential payment would result in the physician getting 99% of the total allowed charges of the eligible professional s physician fee schedule payments in 2012, 98.5% in 2013, and 98% in 2014 Summary Beginning January 1, 2009, CMS will provide an incentive to successful e- Prescribers. The sooner you participate in the program, the greater your incentive payment. Beginning in 2012, if you re not a successful e-prescriber, you will be subject to a differential payment (penalty). You need a qualified e-prescribing System to participate. There s help available to choose a system. Summary Become familiar with the codes for the e- Prescribing Incentive Program Quality Measure. Check with your state officials to make sure you are complying with any e-prescribing requirements specific to your state. You can prescribe controlled substances and still report on the e-prescribing Quality Measure by reporting G-code G8446.

10 Thank you for participating in this seminar presentation from Economedix! Please direct questions to To earn CME credits for this course please complete the Evaluation / CME Form and FAX it back to Economedix within 7 days of the teleconference.